Patient-centered care and interprofessional collaboration in medical resident education: Where we stand and where we need to go

Patient centered care (PCC) and interprofessional collaboration (IPC) remain important goals for all healthcare systems. While these tenets are a cornerstone of training for nursing and allied health professionals (AHPs), their role in internal medicine resident (IMR) training is unstructured and limited. We performed a narrative review to answer two questions, firstly ‘what is known about the attitudes and behaviors of internal medicine (IM) physicians and trainees with respect to PCC and IPC and how does this compare to AHPs?’ and secondly, ‘what evidence based interventions have been trialed to promote PCC and IPC in medical training?’ We searched databases including Cochrane, Medline, Embase, CINAHL and MedPortal. We reviewed 102 publications and found that medical residents tend to value PCC less than non-physician trainees. Hierarchical professional attitudes and a poor understanding of AHP roles are barriers to IPC, whereas diminished time for direct patient care, neglect of the patient’s context and social determinants of health, and lack of self-reflection are barriers to PCC. Published educational interventions for IMRs and AHPs have included classroom sessions, structured ward- and clinic-based interprofessional (IP) work, post-discharge care, home visits, and reflective practice. Interventions were evaluated using questionnaires/surveys, focus groups, tests, primary outcome assessments and ethnographic analysis. The most promising interventions are those that allow learners time for multidisciplinary observation, holistic patient assessments, engagement in care transitions and reflective practice. Based on the review findings we have made recommendations for integration of IPC and PCC training into IMR curricula. Future educational interventions should allow IMR observerships in a multidisciplinary team, introduce residents to the patient’s environment through home visits, incorporate patient/family perspectives in care, and include narrative reflections as part of professional development. Based on our findings and recommendations, these experiences can provide IMRs with much-needed exposure to collaborative, patient-centric care early in postgraduate training.


Introduction
T here is a rising focus on patient-centered care (PCC), interprofessional collaboration (IPC) and medical home models within healthcare systems around the world (Doolittle et al., 2015). However, medical training does not emphasize the skills and values needed to provide 'compassionate, collaborative care' (CCC) (Lown et al., 2016). Orchard et al. (2005) define interdisciplinary care as "a partnership between a team of health professionals and a client in a participatory, collaborative, and coordinated approach to share decision-making around health issues" (Orchard et al., 2005). While these tenets are a cornerstone of training for nursing and allied health professionals (AHPs) (Macdonald et al., 2010;Rotegard et al., 2010), their role in traditional internal medicine (IM) residency training has been unstructured and limited. Current IM residency programs tend to be acute care based; within this setting, PCC training is limited due to inadequate time for direct patient care, lack of follow-up once the patient is discharged, and focus on medical more than the social determinants of health (Schattner, 2017). Another major factor thought to negatively impact PCC is ineffective collaboration amongst health care professionals (Reynolds et al., 1994;Gallagher and Gallagher, 2012) likely attributable to power imbalances, poor communication, lack of confidence and an inadequate understanding of the scope of practice of other disciplines (Orchard et al., 2005). Interprofessional education and collaborative interventions have been shown to have a positive impact on health care processes and patient outcomes (Zwarenstein and Reeves, 2006). Transformation of current medical education models is required to meet to the needs of the future healthcare work force.
A scoping review of 43 articles concluded that PCC must be reinforced as a core value during early postgraduate years so that it becomes systemic, while also shifting education from a uni-professional to inter-professional focus (Gillespie et al., 2017). It is thus increasingly important for internal medicine residents (IMRs) to be trained in patient-centered skills, including communication with patients and community members, and collaboration with multidisciplinary teams in non-acute care settings. The Canadian Interprofessional Health Collaborative has identified six interprofessional competency domains: interprofessional communication, patient/client/ family/community-centered care, role clarification, team functioning, collaborative leadership and interprofessional conflict resolution (Canadian Interprofessional Health Collaborative, 2020). It is the responsibility of IM programs to ensure training in these core competencies to promote skills and positive attitudes in the arena of IPC and PCC.
In this qualitative narrative study, we review the attitudes and behaviors of IM physicians and residents with respect to IPC and PCC as compared to other AHPs. Appreciation of these values is a prerequisite for their adoption through training. In addition, we review educational interventions that have been trialed and observed to promote IPC and PCC amongst IMRs and AHPs. Based on these findings, we make recommendations for enhanced PCC interventions in IMR postgraduate training.

Methods
Identifying the review question. The review questions were discussed and agreed upon by all authors. The first question identified was 'what is known from existing publications about the attitudes and behaviors of IM physicians and trainees with respect to PCC and IPC and how does this compare to AHPs?' The second question was 'what interventions have been trialed and presented in the literature to promote PCC and IPC amongst IM trainees and physicians?' Identifying and selecting relevant studies. Figure 1 summarizes the search strategy used. We searched MEDLINE, CINAHL plus, Cochrane Library, MedEdPortal and Pubmed. Keywords used were internal medicine, training/education/residency, patient/ client-centered care, inter-professional/multi-disciplinary/interdisciplinary and nursing/allied health. Screening of search results was done by the first author using inclusion and exclusion criteria described in Fig. 1. Following the removal of duplicate abstracts, 111 studies were shortlisted for review. However, 3 papers could not be accessed and 6 were found to be irrelevant.
Summarizing and reporting the relevant studies. The remaining 102 papers were reviewed by the first author and manually sorted into one of the following three themes using an inductive approach: (1) description of attitudes and behaviors surrounding IPC and/or PCC; (2) description of one or more interventions to target IPC and/or PCC; and, (3) non-primary research articles describing a need for IPC and/or PCC curriculum or systembased change. The third author then independently reviewed the 102 papers and assigned each to one of the three themes identified by the first author. Subsequently, the two authors met to discuss differences and re-assigned papers to themes as needed. Papers from the three themes are summarized and presented in Tables 1-3, respectively. In instances where multiple articles stemmed from the same research project, the overlapping publications were summarized into the same row. Following summarization, one or more categories was assigned to each paper. Categories were not predetermined but were discerned by the first author after the first round of reviews. The final categories were coded into each theme/table (summarized in Fig. 1). The first author assimilated the findings from papers with a particular category assignment and used the conclusions to design a discussion section that would answer one of the two review questions. The second and third authors then took turns reviewing the categories and the resulting discussion sections and made the necessary changes. Some papers, especially those with multiple assigned categories, were used in more than one discussion section. The discussion sections generally transcend multiple themes, that is, they include papers from one or more tables. Given the variability of publication types, study populations, methods, and outcome measures, we used a qualitative narrative approach to summarize and report data. Table 1 summarizes 37 primary research papers that provided a description of attitudes and behaviors surrounding IPC and/or PCC amongst physicians, medical trainees and/or allied health. Evaluations of attitudes in these papers was done by varying combinations of patients, physicians, trainees, nurses, AHPs and administrative staff, as noted under the 'study population' column. In addition, we summarized salient points regarding the study design and evaluation methods used and provided insights into relevant study conclusions. Table 2 summarizes 36 papers that reported one or more realtime or simulated interventions to target IPC and/or PCC. Realtime interventions were conducted in real patient care scenarios and in the context of real interprofessional teams, whereas simulated interventions included standardized scenarios, theoretical cases and classroom-based learning. In studies involving IMRs/physicians, study populations ranged from 'only IM physicians/residents' to 'collaboration with AHPs or specialities' to working in 'interprofessional teams'. Amongst other nonphysician health professionals, the study populations ranged from graduate non-physician programs, pharmacy, nursing and medical students, internationally educated health professionals, REVIEW ARTICLE HUMANITIES AND SOCIAL SCIENCES COMMUNICATIONS | https://doi.org/10.1057/s41599-022-01221-5 multidisciplinary ward teams, and miscellaneous participants. PCC interventions included classroom sessions, structured wardbased rotations with a focus on post-discharge care, home visits, palliative care experience, reflective practice and a combined IM/ alternative medicine program. IPC interventions included one or more classroom sessions, online sessions, structured ward-based IP learning, continuity clinics, home visits, and systems based practice training. Interventions were evaluated using a

MEDLINE N= 1,703 Identification
What is known about the attitudes and behaviors of IM physicians and trainees with respect to PCC and IPC, how does this compare to other professionals and what interventions have been trialed to promote PCC and IPC amongst IM trainees and physicians?

Duplicate Abstracts Removed N= 24
Papers that could not be accessed N= 3 Coaccioli, 2010;Schuurman et al., 2018;Thrall, 2006 Papers Reviewed N= 102 Theme/ Searched Syntax internal medicine AND (train* OR educat* OR residen* OR intern*) AND (patient-cent* OR clientcent* OR interprofession* OR inter-profession* OR multidiscipli* OR multidiscipli* OR interdiscipl* OR inter-discipl* OR allied health ) Searched Syntax (internal medicine) AND (train* OR educat* OR residen*) AND ((patientcent* OR client-cent*) OR interprofession* OR interprofession* OR multidiscipli* OR multidiscipli* OR interdiscipl* OR inter-discipl* ) Searched Syntax: Searched Syntax: (((internal medicine) AND (train* OR educat* OR residen*)) AND (patientcent* OR client-cent*)) AND (interprofession* OR inter-profession* OR multidiscipli* OR multidiscipli* OR interdiscipl* OR inter-discipl*)  Jackson et al., 2014;Kushida et al., 2015;LaCombe, 2010;Langewitz, 2007;Pugh et al., 2015;Young et al., 2015 Reporting Theme/    Evaluation of physician and allied health attitudes to IPC USA-physicians, AHPs, office professionals and patients in a solo practice, a certified patient-centered medical home and a multiphysician, multispecialty practice An ethnographic approach was used to explore aspects of practice that teams are not aware of or take for granted. This is a field study in three primary care practices based on systematic observation and analysis of human culture.
-Analysis of field notes led to the discovery of recurrent topics or themes, which provided the basis for generating hypotheses -Perspectives were characterized by three labels: the frantic bubble (physicians), the flexible team (office professionals and staff) and in limbo (patients) -physician workdays comprised a series of nonstop, one-on-one patient interactions with little or no interaction with team members -members related to each other similarly in all 3 practices; practice teams operated in separate social "silos," isolating physicians from each other and from the rest of the practice staff Leipzig et al. (2002) Zandbelt et al. (2007aZandbelt et al. ( , 2007b Evaluation of physician attitudes to PCC Netherlands-IMRs and IM specialists (n = 30) and their patients (n = 323) Patients were surveyed to determine the impact of physicians' patient-centered communication on patient satisfaction, adherence, and health status. Specialists' patient-centered communication was assessed by coding behaviors that facilitate or inhibit patient perspectives. Patient participation was assessed by determining their relative contribution to the conversation and their active participation behavior.
-Physician and patient questionnaire followed by a videotaped consultation to assess patient satisfaction -patient self-reported treatment adherence, symptoms and distress 2 weeks later -consultations coded using the Patient-centered Behavior Coding Instrument (PBCI) -Physicians displayed more facilitating behavior when patients were older, reported more physical symptoms, rated patients' health condition as more severe and when the physician was female -physicians displayed more inhibiting behavior when patients reported more physical symptoms and when the physician rated patients' health condition as more severe. -patients were more satisfied after encountering a morefacilitating and lessinhibiting physician, but the effects diminished when controlling for background characteristics -facilitating behavior was positively related to adherence in patients with a foreign primary language -physicians' facilitating behavior was positively associated with patients' relative contribution to the conversation and active participation behavior         combination of questionnaires/surveys, focus groups, one-on-one interviews, pre-and post-tests, objective structural clinical examinations (OSCEs), primary outcome assessments and ethnographic analysis. When coding categories, in addition to categories for IPC or PCC simulated or real-time interventions, we also assigned categories for IMR or non-IMR attitudes to IPC/ PCC if these were revealed during an intervention. An additional category was assigned for the use of narrative reflective practice as an intervention; only 2 such interventions were identified for IMRs and 5 for non-IMRs. Table 3 summarizes 29 articles, reviews, opinions, personal views, reflections, perspectives, commentaries and best practice guidelines that discussed a need for system-based change and/or PCC/IPC curriculum change in medical education. Three of these described a need for narrative reflective practice in curricula.

Discussion
The Institute of Medicine's 2001 report strongly advocated for adoption of PCC (Institute of Medicine Committee on Quality of Health Care in America, 2001) but changes in clinical practice and medical education reform have been slow. We undertook this study to explore the attitudes of physicians and learners towards PCC and IPC and to catalog educational interventions designed to promote these skills in medical education and training. Our review finds concerning trends in attitudes based on professional cultures (Table 1). Physicians think of PCC as an individualized approach to care with a focus on systematic evidence and objective knowledge to improve care (Smith et al., 2015;Sidani et al., 2018). In contrast, nurses and other allied staff perceive it as a team approach with a focus on patient experiences and developing therapeutic relationships (Smith et al., 2015;Sidani et al., 2018). This significant difference may underlie many physicianrelated barriers to IPC including lack of patient centered communication, team engagement, and inclusion of patients, families and other team members in decision-making. Overall, physicians appear to value PCC less than other allied health staff (Gachoud et al., 2012). Alarmingly, this trend was noted even amongst medical students and residents who appear to value IPC and PCC learning significantly less than non-physician counterparts with a lack of improvement in attitudes as training progressed (Kashner et al., 2017). In fact, IMRs in a PCC initiative reported that the physical and learning environment had more impact on their satisfaction than practicing patient-and family-centered care (Byrne et al., 2013).
Physician overconfidence in PCC skills can affect attitude to learning. Physicians' negative attitudes and misperceptions regarding PCC likely influence their perception of need for such training (Table 1). Sidani et al. (2016) showed that physicians rated their PCC abilities higher than their patients' ratings of their skills (Sidani et al., 2016). In an ethnographic study in a cardiology clinic, patients found it difficult to understand and participate in decision-making and indicated that physicians lacked skills related to the non-medical aspects of their diagnosis (Thrysoee et al., 2018), potentially because physicians focus more on the biomedical aspects of their patient's care than on psychosocial domains (Weiner et al., 2007). Physicians probed fewer contextual (51%) than biomedical (63%) hints during patient interviews (Weiner et al., 2010). IMRs and physicians are overconfident in their own PCC skills but in reality, lack the necessary knowledge and communication skills. They inadvertently develop negative attitudes and perceptions regarding this type of learning and therefore, view them as less valuable. These misperceptions must be explicitly corrected; PCC curricula must clearly demonstrate the need for teamwork and create appreciation for year curricula of eight professional health care programs using interactive workshops, hands-on vital sign skills, interviewing standardized patients, identifying simulated safety hazards and recognizing roles and responsibilities through service-learning opportunities -Groups discussions -Nursing learners identified three major themes to represent the education they acquired from participating Categories were assigned to reviewed papers. Categories were not predetermined but discerned after a round of review.

REVIEW ARTICLE
HUMANITIES AND SOCIAL SCIENCES COMMUNICATIONS | https://doi.org/10.1057/s41599-022-01221-5 Table 3 Articles, reviews, opinions, personal views, reflections, perspectives, commentaries and best practice guidelines reflecting a need for curriculum and system-based changes (n = 29). The authors provide background on the Patient-centered Medical Home (PCMH) model; a team-based approach to primary care by physicians, mid-level providers, nurses and AHPs. They discuss challenges in implementing the PCMH model in physician training programs (institutional commitment, infrastructure expenditures and faculty training), present the preliminary success of a pilot project (improvements in quality measures, emergency room visits and cost savings) and propose a strategy for implementation at other institutions. Lown et al. (2016) Perspective (USA) Need for PCC curriculum changes The authors lament that values and skills related to providing compassionate, collaborative care (CCC) are not routinely taught, modeled and assessed in health professional education, postgraduate training and clinical care. They discuss how the CCC framework can be integrated into competency standards and discuss strategies to collaborate with patients and families to ensure person-centered, relationship-based high-quality care. Orchard et al. (2005) Article (Canada) Need for IPC curriculum changes The authors propose a client-centered collaborative professional practice model to promote interdisciplinary collaborative practice (IDCP) amongst healthcare professionals by identifying barriers and enablers. Barriers to IDCP include organizational structure, power imbalances amongst health care professionals and with their clients and role socialization into health disciplines. Enablers include role clarification, role valuing and power sharing. Macdonald et al. (2010) Article (Canada) Non-IMR need for IPC curriculum changes The authors discuss the educational competency 'knowledge of professional role of others' and its associated behavioral indicators, as it relates to the interprofessional education of nursing students. This competency provides a basis to prepare students, preceptors, and faculty for interprofessional practice and develop a tool for performance assessment. Rotegard et al. (2010) Systematic review (Norway) Non-IMR need for PCC curriculum changes The authors examine the concept of nursing health assets based on a systematic review of 60 journal articles and web documents  with Rodger's evolutionary method of concept analysis. They conclude that nursing care should be focused on a person's health assets as a complement to traditionally addressing health problems as this may contribute to improved patient health behavior and outcomes. Schattner (2017) Personal view (USA) Need for PCC curriculum changes The author describes ongoing deficiencies in provision of PCC amongst residents in IM and FM programs including diminished patient 'face time', focus on 'reason for hospitalization/visit' at the expense of 'secondary' medical issues, limited attention to emotional or contextual problems, limited empathy, neglect of habitual 'reflective practice' and excessive distinction between inpatient and outpatient responsibilities. They speculate that limiting resident work hours might limit learning opportunities and quote that IMRs spend only 9-12% of their time in direct patient care vs. 40-51% using the computer. The author therefore expresses a need to redesign residency programs to incorporate PCC as an integral part of training. Reynolds et al. (1994) Article (USA) Need for IPC curriculum changes The authors make recommendations to promote collaboration amongst general physicians including resident IPE, creation of an institutional collaborative curriculum committee, design of a longitudinal curriculum on collaboration, implementation of collaborative patient care in ambulatory clinics and development of integrated systems of care that link inpatient and community-based health services. Gallagher and Gallagher (2012) Reflections (Ireland) Need for IPC curriculum changes Non-IMR need for IPC curriculum changes The authors highlight the importance of effective, deliberate collaboration between doctors and pharmacists in providing good patient care in hospitals and clinic settings. They review factors that help or hinder IP working relationships and discuss strategic practice changes such as interprofessional education and standardized medical education in optimal prescribing. Zwarenstein and Reeves (2006) Systematic review (USA) Need for IPC curriculum changes The authors present a systematic review of the impact of interprofessional education and collaboration interventions on interprofessional relationships, health care processes, evidencebased practice, knowledge translation and patient outcomes. They highlight the need for rigorous multimethod research studies in these areas. Gillespie et al. (2017) Literature review (UK, Canada) Need for PCC curriculum changes The authors conducted a scoping review with a phenomenological orientation to report patients' experiences of caring and characterize uncaring experiences. The review of 43 articles based on nursing, medicine, and physiotherapy in varied care settings revealed that "patients experienced caring when competent professionals displayed positive attitudes, communicated effectively, formed relationships, engaged emotionally and helped navigate clinical services". Kathol and Kathol (2010) Comments and responses (USA) Need for PCC curriculum changes Need for system-based interventions This is a comment on the 2010 paper by Weiner SJ et al. titled 'Contextual errors and failures in individualizing patient care: a multicenter study.' The authors highlight that physicians who avoid contextual errors are those that consider the patients' context not as an afterthought but instead as a part of the clinical reasoning process; they believe that such reasoning processes can be effectively taught. They also propose that specialized support personnel such as case managers and midlevel providers could help provide contextually appropriate care. Heyrman (1995) Article (Belgium) Need for PCC curriculum changes The author describes patient-centered models of care including goal orientation and functional care models, quality of life measuring instruments and multimedia education.  The authors describes an ideal academic Department of Medicine program in USA that responds to projected shortage of physicians through training strategies, creates clinical programs that value PCC, modifies educational programs to ensure trainees are proficient in core competencies, develops adaptable structures where physicians improve care by engaging in IPC, aligns clinical, research and scholarly activities and invests in faculty career development, infrastructure, interdisciplinary research teams and funding sources. Weinberger et al. (2014) Ideas and opinions (USA) Need for PCC curriculum changes The authors advocate for efforts to implement patient-and family-centered care (PFCC) in medical education by altering faculty behavior and evaluating models that effectively incorporate input from patients and families. For example, patients and families can display active roles as teachers and advisors and provide feedback on individual trainees and program effectiveness. Faculty can also encourage discussions about patient and family perspectives in patient notes and teaching venues. Maynard and Heritage (2005) Article (USA) Need for PCC curriculum changes The authors discuss the field of conversation analysis (CA) and its contributions to the understanding of the doctor-patient relationship, especially in IM clinics. They also provide suggestions on incorporating CA into the medical curriculum to promote biopsychosocial, patient-centered and relationship-centered approaches to communication. Smith et al. (2005) Perspective (USA) Need for PCC curriculum changes The authors discuss the importance of considering attitudes that influence whether a learner will utilize taught clinical skills and present a research-based method for teaching personal awareness of negative attitudes. They propose that selected PCPs can serve as teachers/ mentors to teach the personal awareness to students, residents and faculty, through instruction in basic interviewing skills in addition to systematic incorporation throughout training. Meyers et al. (2007) Best practice guidelines (USA) Need for PCC curriculum changes The authors describe six recommendations made by the 'Alliance for Academic Internal Medicine Education Redesign Task Force' to improve internal medicine residency education. Strategies include using a framework to focus structure and content of IMR educational experiences, fully adopting learner-specific competency-based education, allowing for increased resident-centered education outside of the IM core, improving ambulatory training and longitudinal care opportunities, using new models to create a core faculty and aligning institutional resources with educational needs. The authors further highlight the need for pilot projects, changes in accreditation requirements and modifications to funding systems. Horwitz et al. (2011) Review (USA) Need for PCC curriculum changes The authors conducted a review to assess the quality of IM training programs and identify guiding principles to restructure programs rationally. Identified areas of focus included patientcentered small group teaching and greater incorporation of clinical epidemiology research. They also proposed a Cooperative Educational Studies Group of training programs to create a common targetable data set. Jean-Jacques and Wynia (2012) Opinion (USA) Need for PCC curriculum changes This is an opinion piece based on the 2012 publication by Ratanawongsa N et al. where the IM ward team was redesigned to incorporate a PCC curriculum, a substantial reduction in patient load and a more engaged and structured role for attending physicians providing direct supervision and feedback to residents. In this opinion piece, the authors describe the redesign team as a success with higher IMR ratings and greater patient satisfaction, thus advocating for similar reforms in other programs. Kane et al. (2011) Commentary (USA) Need for PCC curriculum changes The authors comment on semi-structured interviews with 20 IM program directors exploring practice-based learning and improvement, systems-based practice, interpersonal and communication skills, care setting and IT infrastructure. They discuss the ongoing need to collect and provide quality feedback to IMRs and develop value-added QI programs. Liao et al. (2015) Perspective (USA) Need for narrative reflective practice in curriculums The authors recommend the use of narrative medical writing as a viable professional and communication skill in graduate medical education (GME) to promote provision of patientcentered health care by internists. This has been limited by local and system factors however the authors suggest implementable strategies especially by supporting initiatives in population health management, quality improvement and health disparities. Kirkpatrick et al. (1997) Article (USA) Need for narrative reflective practice in curriculums The authors discuss narrative reflective practice in the form of storytelling as a way to enhance trainees' sensitivity to illness, humanity, death, dying and advance directives. The use of storytelling is common in nursing education programs and has potential to motivate and inspire human sensitivity skills needed by other interdisciplinary healthcare providers. Prowd et al. (2018) Best practice guidelines (Canada) Need for system-based interventions This article describes best practice guidelines implemented by a Canadian Public Health Unit for improved delivery of client-centered care including "building an interdisciplinary team, adapting Registered Nurses' Guidelines to reflect public health practice for nursing and other disciplines, developing a working definition of 'client', engaging staff in knowledge translation, developing policy to support practice change, and incorporating client-centered care principles into daily practice" Monrouxe et al. (2017) Literature review (UK) Need for IPC curriculum changes The authors conducted a literature review of primary research studies to characterize UK medical graduates' preparedness and effectiveness of workplace transition interventions. They concluded that graduates are prepared for history and physical taking and some clinical skills but unprepared in areas such as multidisciplinary team-working, prescribing and clinical the value of AHPs. As noted by Kathol and Kathol (2010) in Table 3, learners must attend to the patient's narrative and environment, not as an afterthought, but as part of the clinical reasoning process (Kathol and Kathol, 2010).
Physicians practice and value IPC less than allied health professionals. Evidence suggests that physicians do not value IPC as much as AHPs (Table 1) likely because they do not understand the varied interprofessional roles or fully appreciate their impact on patients (Muller-Juge et al., 2013;Card et al., 2014;Bochatay et al., 2017;Kashner et al., 2017;Garth et al., 2018). A qualitative study of General Internal Medicine (GIM) wards in Toronto identified several gaps in communication and collaboration between physicians and other AHPs (Zwarenstein et al., 2017). AHPs had frequent deliberative discussions about patients amongst themselves whereas physician interactions with AHPs were limited mostly to structured rounds; physicians made decisions mostly in isolation (Zwarenstein et al., 2017). In another ethnographic field analysis, Chesluk et al. 2010 found that physicians set a hectic pace within an isolated 'bubble', seeing patients non-stop and isolating themselves from their staff and other office professionals (Chesluk et al., 2010). In another study, residents were least inclined, amongst AHP students, towards interdisciplinary work; they were less likely to agree that IPC benefits patients and is a good use of time (Leipzig et al., 2002). Profession-focused rather than patient-or team-focused goals, negative stereotyping and hierarchical communication (Thomson et al., 2015) may result in physicians not always prioritizing multidisciplinary rounds, not asking team members for input, or keeping them informed (Garth et al., 2018). Physicians have been trained in a culture where they believe that the team exists to support them: this attitude is negative to team functioning as members may feel disrespected and ignored, leading to decreased confidence and reciprocity (Sidani et al., 2016). Physicians likely lack insight into their own deficiencies (Sidani et al., 2016) thus highlighting the need for ongoing interprofessional education through school, residency, and practice.
Transforming medical culture is an important first step in promoting PCC and IPC. As shown in Table 3, quality of care improves when it is patient-centered, but medical education is still predominantly disease-centered and teaches individual approach to care (Heyrman, 1995). In order to transform healthcare, it is important to change the culture of the people who practice it (Ruddy et al., 2016) and the institutions where they work. When Horsburgh et al (found in Table 1) surveyed students accepted into undergraduate medicine, nursing and pharmacy programs, they found that professional sub-cultures were present even before they had commenced their education (Horsburgh et al., 2006). Medical students believed that clinical work was the responsibility of individuals, nursing students believed in a collective view, and pharmacy students were at a midpoint in views (Horsburgh et al., 2006). This raises the possibility that our current approaches to selection may be biased towards selecting students for different healthcare professions based on their attitudes and social predilections (Horsburgh et al., 2006). Medical school admission committees must be able to select for learners in medicine with more patient-centric attitudes.
Additionally, IM physicians must also be encouraged to role model patient-centric and collaborative behaviors. Rice et al. (2010) (Table 2) found that senior physicians, nurses and AHPs minimally explained plans for an intervention to junior colleagues and rarely role-modeled PCC supportive attitudes and behaviors. Role-modeling cannot be done well in the current fast paced, interruptive environment with rare and impersonal interprofessional communication and absence of continued leadership and management support (Rice et al., 2010). In addition, staff may themselves not have the required training given what we know about shortcomings in medical education with respect to PCC. Changing individual and institutional culture requires long and Best practice guidelines (USA) Need for system-based interventions The authors describe the Choosing Wisely initiative aimed to promote conversations around tests and procedures whose necessity is questionable within the context of each patient's care plan. They summarize relevant domains including "the strength of evidence for a particular recommendation, a general internists' "standing" on the topic, the number of patients likely to be affected by the recommendation, the financial impact, the relative cost effectiveness of the intervention and potential harm to the patient. They additionally direct readers to 280 potentially unnecessary medical tests identified by medical societies and consumer groups. Morris (2011) Opinion (USA) Need for narrative reflective practice in curriculums This is an opinion piece by an IMR who reflects on observations of PCC provided in a pediatric neonatal ICU and compares this with personal experiences on GIM wards. This self-reflection moved the IMR to practice more patient-centric care while minimizing iatrogenic suffering for patients. Edmond (2010) Opinion (USA) Need for PCC curriculum changes The author conveys a criticism of modern medicine and restricted resident work hours. He nostalgically states "when I think back on the aspects of internal medicine that drew me in as a student, it was the internists' unrushed, careful approach to the patient; their attention to detail; how they interacted with their colleagues and students; and, above all, the time they spent discussing interesting cases that left an indelible impression on me." Conn et al. (2009) Article (Canada) Need for IPC curriculum changes The authors report an ethnographic study of interprofessional communications on two GIM wards through the lens of communication genre theory. They categorize communication as synchronous or asynchronous and find that these have an essential relationship in promoting IPC and can be coordinated to overcome existing communication barriers.
Categories were assigned to papers. Categories were not predetermined but discerned after a round of review.
sustained efforts. As suggested in Table 3, in addition to training future physicians, academic programs must focus on faculty development and evaluation for existing staff (Coleman and Johnson, 2016). Institutions need to provide a supportive and accommodating environment and further skills development, for example training physicians in competence based evaluations. Other strategies include promoting diverse and longitudinal mentorship for learners (Coleman and Johnson, 2016).
PCC curricula including didactic learning, observerships, home/hospice visits and patient/family participation report improvements in PCC amongst IMRs. Several PCC educational interventions have been developed and evaluated. Majority of curricula reported a subjective or objective improvement in PCC delivery (Table 2). A curriculum with didactic learning using patient simulations and interview techniques showed objective improvements in a scoring system based on biomedical versus patient-centric conversation analysis (Maatouk-Burmann et al., 2016). IMRs who joined a ward team as a quality officer reported improved awareness of fragmented care, interprofessional roles and patient perspectives (Meade et al., 2015). Improvements were also noted when IMRs observed and managed gaps in postdischarge care through phone-calls, clinics and home visits (Record et al., 2011;Ratanawongsa et al., 2012;Schoenborn and Christmas, 2013;Meade et al., 2015). Residents who participated in home hospice visits were more likely to discuss bereavement support and recommend hospice in subsequent practice (Espada et al., 2015). Both IMRs and patients in the Aliki initiative reported higher satisfaction in transitional care, medication adherence and patient understanding, likely attributable to decreased IMR workload, structured post-discharge care and reflective exercises (Ratanawongsa et al., 2012;McMahon et al., 2010;Hanyok et al., 2012). The deliberate practice of observing and working with teams enhanced communication and collaboration skills. IMRs must understand the value of effective interprofessional teamwork for the PCC curricula to change behavior. As future healthcare workers, our learners will be called upon to deliver more community-based care through patient-centered medical home (PCMH) models and home visits. In a survey of 179 participants, both residents and faculty felt unprepared and reported lacking knowledge for PCMH activities; the authors attributed this to the lack of a formal PCMH curriculum (Block et al., 2017). Medical education should provide training that is sensitive to various care settings and not focus on acute care alone. Home visits can facilitate PCC learning by opening IMR's eyes to the patient's contextual environment, may ensure effective care transitions, and better end of life care through home hospice exposure (Record et al., 2011;Espada et al., 2015). In Table 3, Gillespie emphasizes that PCC curricula needs to train residents in patient-centric tasks such as planning and managing care, educating the patient on navigating the system and enhancing continuity through effective teamwork beyond evidence based care (Gillespie et al., 2017).
As suggested by Weinberger et al. (2014) in Table 3, patients and families can be involved as more active participants to promote Patient and Family-Centered Care (PFCC). They could act as 'faculty', advisors and discussion facilitators in postgraduate resident education and not only be a source of learning but could also provide feedback to the resident and program (Weinberger et al., 2014). Students in a longitudinal curriculum described in Table 2 perceived this intervention to have a positive impact on PFCC (Parent et al., 2016). This is essential for learners to understand the value of team based care from the patient's perspective.
IPC curricula promote interprofessional understanding especially with IMRs as active observers. IPC interventions as part of PCC curricula (Table 2) involving didactic learning (Kowitlawakul et al., 2014;Nothelle et al., 2015;Gupte et al., 2016;Janssen et al., 2017;Sordahl et al., 2018) and/or ward-based (Nabors et al., 2011;Hemming et al., 2016a) or clinic-based patient care (Soones et al., 2015) might improve IMRs understanding of AHP roles and create greater appreciation for their work. A longitudinal interprofessional education (IPE) experience comprising didactic learning, clinic and home visits led to significant improvement in interprofessional attitudes, respect and conflict management even though the intervention did not affect beliefs regarding the effects of IPE on patient outcomes (Hanyok et al., 2013). IMRs are better able to "learn" PCC and IPC traits when observing AHPs, versus interactions in traditional clinical contexts where meaningful collaborations may not occur. A classroom-based IP curriculum with modules, case studies, simulation and shared case planning (Zook et al., 2018) as well as a ward-based IP curriculum focused solely on teaching communication (Rice et al., 2010) had minimal impact on attitudes to IP care. Soones et al. (2015) noted that including residents in IP teams may not be enough to teach the impact of team-based care and that the culture of ultimate resident responsibility negatively impacted team based care (Soones et al., 2015). This suggests that effective educational interventions should allow residents to be a learner in the team with the flexibility to observe AHP roles and not be the responsible provider.
Narrative self-reflection through story-telling and conversation analysis has a positive impact on PCC. Kirkpatrick et al. (1997) ( Table 3) state that narrative reflections and storytelling "enhance the learner's sensitivity to the illness experience" and help develop respect and empathy for patients, other professionals and self (Kirkpatrick et al., 1997). As described in Table 2, self-reflection is now regarded as an essential professional skill that can be developed through the practice of narrative writing. The John Hopkins Aliki initiative incorporated narrative self-reflective practice into their IM program (McMahon et al., 2010;Ratanawongsa et al., 2012;Schoenborn et al., 2013) with good results. Their residents noted an improvement in their ability to know their patients as people and rates of patient satisfaction also improved (Ratanawongsa et al., 2012). Creating pedagogical space for reflections and mutual sharing can help break down power differentials and reform worldviews based on shared values (Dellasega et al., 2007). Despite benefits, self-reflection is not frequently used in medical training; it has been studied more frequently in interprofessional curricula created for AHPs (Dellasega et al., 2007;Hanson, 2013;Schwind et al., 2014;King et al., 2017).
Conversation analysis (CA) is a tool to help increase personal awareness and facilitate self-reflection (Table 3). It can also be used as an evaluation tool in medical education for feedback and improving patient centered communication competency (Maynard and Heritage, 2005). Reviewing recorded conversations with skilled educators can shed light on unrecognized tendencies and behaviors in trainees during patient interviews including fear of losing control, performance anxiety, over-control by interrupting the patient, avoidance of psychological material such as death, and superficial behavior such as being overly reassuring and passivity (Smith et al., 2005). These attitudes are incompletely recognized by learners and are difficult to change without help (Smith et al., 2005).
Strategies for curriculum and system-based changes to promote PCC and IPC in healthcare. Unfortunately, in the current model of IMR training, PCC is presumed to occur but not directly addressed. Several reviews and opinion pieces in Table 3 highlight the inadequacies and provide suggestions for curriculum and system-based changes (Reynolds et al., 1994;Orchard et al., 2005;Meyers et al., 2007;Horwitz et al., 2011;Jean-Jacques and Wynia, 2012;Doolittle et al., 2015;Coleman and Johnson, 2016;Ruddy et al., 2016). When an interdisciplinary American initiative tried to transform residency training in family medicine, IM and pediatrics, their efforts were limited by institutional missions, difficulty in engaging stakeholders, and collaborative challenges in developing uniform measures, despite 97% of faculty members reporting an intention to implement PCC (Carney et al., 2015). PCC initiatives will have to overcome many such barriers to implement changes. As alluded to previously, entraining supportive institutional cultures is key to developing the education and clinical space for practice of PCC.
The Alliance for Academic Internal Medicine Education Redesign Task Force has made six recommendations to improve IMR education including improving longitudinal and ambulatory care training, aligning institutional resources with educational needs and adopting resident-specific competency-based education (Meyers et al., 2007). The move towards competencybased education requires that entrustable professional activities (EPAs) such as "recognizes nonverbal cues", "actively listens", "responds to emotions" and "practices self-reflection" be developed for resident evaluations (Lown et al., 2016). Other strategies include reduction in patient load that provides time for meaningful, deep reflection (Jean-Jacques and Wynia, 2012); effective, deliberate IPC (Gallagher and Gallagher, 2012), implementation of PFCC (Weinberger et al., 2014), continuous quality improvement (Kane et al., 2011) and as discussed in Table 2, introduction of humanities courses (Dellasega et al., 2007). Smith et al. (2005) present a method for teaching personal awareness of negative attitudes; this can be used by faculty/ teachers/mentors to facilitate IMR insight needed for change (Smith et al., 2005). At a foundational level, departments of medicine must address physician shortages, create adaptable clinical programs that are more responsive to patient preferences, prioritize PCC curricula and training, promote investments in interdisciplinary research teams and "team science", ensure diversity in educational leaders and focus on population management and social determinants of health (Coleman and Johnson, 2016).
Recommendations for educational interventions.
1. Postgraduate medical education must include a curriculum to foster competency in interprofessional PCC. IMRs must develop clarity in their own role as physicians and understand the roles of AHPs in order to allow positive collaboration, shared decision making and patient-centric goals. The focus of patient interviews must expand from biomedical assessment to a broader patient context including appropriate needs assessment. 2. An interprofessional PCC curriculum may be a mix of didactic, simulation and real-world experiences that allow IMRs to observe, participate and deliver PCC over the learning continuum. Educational interventions should allow IMRs to be observers of AHPs in the team rather than continuing their professional role in the context of an IP team. Observation plays a key role as it liberates learners from additional responsibility of actual care delivery during these periods. 3. In addition to acute care, multiple care settings must be integrated into curricula such as ambulatory care, community-based programs and multidisciplinary practices.
4. Home visits, hospice and palliative care should be integrated into curricula to help residents develop a global overview of patients' experience and develop an insight into humanistic individualized approaches from initial presentation to disease progression to end of life care spanning the entire patient journey. 5. Narrative self-reflection should be integrated into curricula.
We recommend one or more narrative reflection exercises for IMRs to encourage consolidation of their experiences. This will lay the foundation for empathetic care while focusing on the patients' psychosocial context and recognizing their own personal journey through medicine. Conversation analysis (CA) is an additional tool to help increase personal awareness and facilitate self-reflection. 6. PCC evaluation must be revamped by developing entrustable professional activities (EPAs) to assess communication, respect, and empathy in the curriculum and by adopting learner-specific competency-based education. 7. Patients and families should be included in postgraduate resident education as 'faculty' and advisors who can educate and provide feedback. Dedicated space and time for IMRs to understand illness from the patient perspective will promote awareness of gaps in care and learning. 8. Faculty development is needed to facilitate culture change in education and practice. IM physicians need to role model patient centric and collaborative behaviors to support and sustain a patient centered attitude in care and education. 9. Medical school admission committees must select for learners with more patient-centric attitudes. 10. Interventions should be implemented at the institutional level. These include decreasing IMR workload, targeting physician shortages, structuring post-discharge care, engaging stakeholders, aligning institutional resources with educational needs, creating flexible educational programs, increasing funding for interdisciplinary research and hiring diverse educational leaders and physicians skilled in PCC.
Limitations and future directions. This is a narrative summary of the literature and many interventions did not measure or report objective findings, making it challenging to assess usefulness of the intervention ( Table 2). The majority of interventions described an objective or subjective impact on IPC and/or PCC; only a few were considered to have failed and thus our review lacks dissenting views. This raises a potential for bias and a possibility that the search strategy was not broad enough. This review has focused on PCC and IPC interventions for IM residents and physicians while excluding interventions based solely on medical students from the search. In recent years there has been a significant uptake of interprofessional education (IPE) curricula across programs that teach medical, nursing, and allied health students in a combined, structured curriculum. Further reviews could be undertaken to explore the success of these curricula in promoting PCC and IPC as these students progress in their careers.

Conclusion
As healthcare transitions towards patient centered, communitybased care and medical home models, it is becoming increasingly important to train medical residents with the skills to achieve competency in these extended practice areas. This review sheds light on deficient physician skills and attitudes in the arena of patient-centered care, especially when compared to AHPs who receive this foundation early in training. Hierarchical professional attitudes, poor understanding of AHP roles, diminished time for direct patient care, neglect of the patient's context, inability to identify and address non-medical problems through effective communication and interprofessional collaboration, and lack of self-reflection are barriers to PCC. This review also highlights the need to deliberately expose and train medical residents in interprofessional interventions and collaborations early in their education in order to improve their outlook and understanding of the roles of other disciplines. The most promising PCC and IPC interventions are those that allow learners time for observation of a multidisciplinary team in action, making holistic patient assessments, developing collaborative care plans and opportunity for reflective practice. Future educational interventions should make space for IMRs to be observers, provide experiential opportunities in non-acute care settings, introduce residents to the patient's environment through home visits and patient/family feedback, and incorporate narrative reflections to deconstruct experiences and assimilate new learning.

Data availability
All data generated or analyzed during this study are included in this published article Received: 12 January 2021; Accepted: 7 June 2022;